Very early invasive investigation does not improve long-term outcome when NSTEMI ACS is suspected
ESC 2018 - Munich
The VERDICT trial: Early versus deferred diagnosis and treatment of NSTE-ACS patients
Presented at the ESC congress 2018 by: Thomas Engstrom (Copenhagen, Denmark)
Introduction and methods
The standard of care for individuals with a suspect non-ST-elevation acute coronary syndrome (NSTE-ACS) is coronary angiography with 48-72 hours, followed by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. It is hypothesized that a very early invasive diagnosis and treatment strategy, with a coronary angiography no later than 12 hours after symptom onset, followed by PCI or CABG, may be of additional benefit for these patients.
In the VERDICT study, patients, aged >18 years, with a clinical suspicion of ACS, and an ischemic ECG or increased biomarker levels, after receiving dual antiplatelet therapy, fondaparinux, and betablockers, were randomly assigned 1:1 to either the standard (coronary angiography within 48-72 hours followed by PCI or CABG), or the very early invasive treatment strategy. The primary endpoint was the composite of all-cause death, recurrent myocardial infarction, heart failure or refractory ischemia.
- 2,147 patients were followed-up for a median of 4.3 years.
- 32% of all patients had no coronary artery disease.
- The primary endpoint occurred in 27.5% of patients in the very early group and in 29.5% of patients in the standard group (HR: 0.92; 95%CI: 0.78-1.08; P=0.29).
- Among various subgroup analyses, the subgroup of patients with a GRACE score >140 showed an HR for the primary endpoint of 0.81 (95%CI: 0.67-1.00) as compared to those with <140.
A very early invasive diagnostic and treatment strategy was not superior to standard treatment of all NSTE-ACS patients, in terms of reducing all-cause death, non-fatal recurrent myocardial infarction, hospitalization for heart failure or refractory myocardial ischemia rates, but it may be justified in the subgroup of patients with a GRACE score >140.
After the presentation at the ESC Press Room, it was questioned whether the benefit for patients with a GRACE score >140 may have been a play of chance. However, this was a pre-specified subanalysis and there was enough statistical power for a robust result. It was also discussed that high risk NSTE-ACS patients should not be defined only based on troponin levels, but also based on traditional CV risk factors. This is relevant as many patients had elevated troponin, but many did not have CAD.
It was noted that there were no differences in bleeding rates between groups, and that a very early treatment strategy is therefore safe. However, due to the logistical challenges of bringing all NSTE-ACS patients to the cath lab within 12 hours, it should be applied to the appropariate patients only. Earlier distinction of who is at high risk will benefit patients. Moreover, if the right patients are identified, who need an immediate angiography, and in others at a lower risk, the angiography can wait, resources are used appropriately.